etiology of Keloid formation of the skin is unknown, but the condition is ... arise frequently, under such circumstances, it would seem that little attention has ... for many years, and one of her brothers had much wheezing in his- chest at times ...
KELOID AND ^
(g>
SELF ADMINISTRATION OF
ADRENALINE^
C. KELMAN
ROBERTSON,; M.D.,
D.P.H., F.R.C.P.E.
"Royal Infirmary, Edinburgh
The etiology of Keloid formation of the skin is unknown, but the condition is
burns,
common
enough
scalds, vaccination,
in
everyday practice,
in association with
scars, etc.
The development of this curious change would appear to be the result of an individual skin characteristic, and not one that is dependant upon any known bodily state. A tuberculous diathesis was at one 'time promulgated but is now regarded as not only unlikely but as having nothing to support it. There is no relationship between the Slze of the original scar and the onset of a Keloid because the change ls known to appear after trivial injuries such as pin pricks and insect bites. This being so it might be expected that Keloids would be fairly frequent in people who undertake the self administration of insulin, adrenaline or use a syringe in drug addiction. If the change does arise frequently, under such circumstances, it would seem that little attention has been drawn to it, and for this reason the following case is to be worth placing on record. History.?A girl of 19 years was admitted to hospital on 10.6.51, With a history of having suffered from asthma since the age of four.
thought
Her attendance
at school had always been very irregular owing to the of the paroxysms and she had finished schooling at thirteen. She was unable to follow any employment after leaving school, but had taken part in the housework, at home, under her mother's guidance. At the age of fifteen the attacks of asthma started to become really had and two years later it was found that the only thing that could c?ntrol them was an injection of adrenaline. As many other forms ?f oral and inhalation therapy had been tried without avail she was accordingly instructed, at this time, how to give herself injections of this drug. The attacks were so frequent and prolonged that on many
frequency
"
"
occasions she had recourse to give herself seven or eight injections in the day, averaging, in amount, anything between \ and 1 c.c. Six months after she started
giving herself the injections she noticed beginning to form on both her upper arms at the Peaces where she was inserting the needle. The scars were never painful or itchy and she could force the hypodermic needle through them without any undue discomfort, hut she made it a practice, when she remembered, to inject the adrenaline at their edges. When she found that the scars on her arms were increasing in size she began giving herself the injections ir>to the fronts of her thighs, but as this brought about a similar reaction that
scars
were
vol. lviii.
no.
11
S5S
202
C. KELMAN ROBERTSON
556 she
desisted from using these areas. She then tried injecting" the front of the abdomen but soon realised that the same change was prone to take place there. The patient stated that both syringe and needle, which she used, were kept submerged in surgical spirit, and that they were carefully boiled for twenty minutes before use.
quickly
the skin
on
There
known
her attacks, her been an asthmatic for many years, and one of her brothers had much wheezing in his" chest at times associated with hay fever." was
no
paternal grandmother
was,
precipitating factor for however, reputed to have
Clinical Examination.?Pale young woman, mouth-breather with
typical asthmatic type of wheezing. No finger beaking. Occasional cough with very little sticky mucoid sputum. Heart sounds normal, pulse rate 92 per minute B.P. 118-78. On the upper lateral aspects of both arms were raised, red, ugly looking irregular Keloids, measuring 9 cm. long by 4 cm. broad which touch. Similar smaller areas of scarring were were not tender to on the inner side of the thighs, also two small patches on the present No associated glandular enlargement was noted. lower abdomen. It was observed that there was of the left hand, resulting from show Keloid change. No other
a
small well-healed scar on the back minor injury but which did not
some
bodily scars were noted. Special Investigations.?Blood examination?Hb. 95 per cent., eosinophils 15 per cent., B.S.R. 9 mm. plasma in first hour. X-ray?increased broncho-vascular markings and emphysema. Right maxillary antrum slight opacity. Sputum?small number of mixed organisms, the predominant type being pneumococci (penicillin sensitive). There were numerous polymorphs, many autolytic and the proportion of eosinophils was high, about 25 per cent. Five specimens were negative for M. tuberculosis. Fasting gastric juice?two samples negative for Cultures of
for tubercle. MantouX Blood test?negative. sugar curve?normal. Skin tests reactions to fish, cereals and pollen B. positive gave sensitivity A culture plate was inoculated with the hypodermic needle that was used by the patient and this gave no growth except for a few colonies M. tuberculosis.
above?negative
E.C.G.?normal.
Staphylococcus albus and Micrococcus tetragenus. A biopsy specimen was taken from the Keloid and adjacent normal dermis on the left upper arm. The microscopic report on this (Dr of
Robertson Ogilvie) was :? " Marked overgrowth of fibrous tissue in the subcutaneous region. The new tissue is disposed in more or less contiguous oval masses and is therein made up of interlacing fasciculi of moderately cellular and substance. Off-shoots extend into the underlying fat. The fibrous region is supplied by fairly plentiful vessels grading from capillaries to small sinuses and many of them show cuffing with round cells and some siderophages. Hair follicles sebaceous and sweat glands are absent.
highly collagenous "
Fig. i.
?
i-.
ETT ???
TBI
_
Fig. 2.
KELOID AND SELF ADMINISTRATION OF ADRENALINE
557
The overlying skin is about average thickness, but has an unusuallyflattened appearance compared with the neighbouring epidermis Presumably due to subjacent pressure. The features of the specimen are
those of
Keloid." the Although patient had no real need to have a bronchodilator "while in hospital, she was asked to demonstrate her method of giving herself adrenaline. This she did remarkably well, but it was noticed that after she had given herself two small injections in the left forearm that a small hard lump was forming which would no doubt have
become
a
a
Keloid had she continued. was sought regarding the
Advice
for the Keloids, but it
Summary.?The
was
advisability of X-ray therapy thought likely that this would help. of an unusual case of Keloid arising as
not
details
the result of the self administration of adrenaline for asthma
are
recorded.
There did condition
The
dermic
was
cause
not
appear
to
be
needle. No record of
a
am
ward.
tuberculous diathesis present and the with
a
hypo-
be traced in the literature. the hospital staff who had many years on both asthmatic and dermatological problems
similar
case can
Senior colleagues experience of seeing expressed the opinion that the I
a
presumably a personal skin characteristic. was undoubtedly trauma to the epidermis
case was
indebted to Dr James K. Slater for
unique. permission
to
publish
this
case
from
